840. You are saying that is what Professor Aeschbach
did?
(Professor Rehm) Yes.

841. Dr van Santen, are you familiar with Professor
Aeschbach's paper?
(Dr van Santen) I am not a researcher.

Mrs Dean

842. Professor Rehm, is the main aim of the
programme to help people out of their addiction or to manage their
addiction and improve their general health and well being?
(Professor Rehm) What we are trying to do is have
a succession of goals. The long-term goal is still abstinence.
We say that we can show this long-term goal only by intermediate
steps of helping them in their day-to-day lives. I think the most
convincing figure we have is that if people stay in heroin assisted
treatment for longer than three years those who leave treatment
have about a 30 per cent chance of going into abstinence treatment.
When we said that at the beginning, that this is a long-term goal,
they said, okay, are you speaking from both sides of your mouth.
You can say a lot about long-term treatments, we will no longer
be there, you will no longer be there. The longer the people stay
in treatment the more chances there are to go even to abstinence
or methadone treatment, try it again. The question is, of course,
how much is enough. The question is, when should we make more
effort to actually make them go rather than them deciding by themselves
that they have to fight for six years. We currently have a big
debate within the treatment community and between researchers
and the treatment community on measures, how to actually move
those long term people out into whatever, usually abstinence.
I think long term you do have success. We have only done six years
of programming. Most of the people who started six years ago are
out, lots of them tried abstinence treatment. We have people who
go into abstinence treatment, make the first step, withdraw completely
but that does not mean they have long term success. Any kind of
treatment in the addiction field cannot guarantee long term success,
at least it is a positive indication.

843. Do you have figures for how many are drug
free and correspondingly do you have figures of how many relapsed?
(Professor Rehm) That is a very difficult undertaking.
Overall after two years it was the same addiction still, that
is one of the problems of comparing those different things.

844. In the journal, in the Lancet it
talks about one, two and three admissions and treatments, could
you explain a little bit more of how people are admitted and how
they then finish on that one treatment session and come back.
Do they instigate that or do you?
(Professor Rehm) There are rules and if they violate
the rules they are kicked out of the treatment. Non violence is
probably the strictest rule. Clearly if one of the drug addicts
is causing harm or threatening to cause harm verbally to staff
they are kicked out of the programme. Those happenings usually
come pretty early, those people are terminated within six months
to one year, sometimes even earlier. Then there are treatments
where basically it is an interaction between the treatment, persons
and their client, meaning they facilitate, they say, you have
been stable now we have your word, why are you still coming here
three times a day, would it not be better to go on methadone you
can take home or go to abstinence. This kind of interaction is
the usual case I would say. Then there are terminations of the
people by themselves without any facilitation, even sometimes
against the councillor, those would be for people who would say,
I was HIV-positive when I came in here, all I want to do is die
now, I want to go out, that is it. That happened in some individual
cases. People were saying by themselves, look you do not believe
I can do abstinence but I am trying abstinence.

845. People would also be counted as coming
off the treatment if they went into abstinence treatment.
(Professor Rehm) Of course if they went into abstinence
treatment they would get medical withdrawal, that is their right.
They are phased out and they start their abstinence treatment.
All of our abstinence treatment in Switzerland have a requirement
that you have come in be abstinent and after withdrawal.

846. Can I turn to Doctor van Santen, it is
basically the same question I am asking, the aim of the programme
as far as you see it, whether it is to try and get people off
drugs or to improve their life-style?
(Dr van Santen) The issue of abstinence, by that you
many even without any medication.

847. Yes. Either.
(Dr van Santen) It has to do with the selection of
patients. We have a public service and we concentrate ourselves
on the severe cases which have become very chronic and difficult
to reverse. The issue here is a selection of patients, I think.
There is a network development of addiction. Studies show the
longer the duration the more difficult it is to reverse an addiction.
If you select patients with a short history the chances of abstinence
and the reversion of the addiction are good and in chronic cases
are very difficult. In this discussion I think we missed the nature
of addiction itself, because it is a common thing, especially
for us because we have severe cases. We talk about success and
the consumption of illegal substances has stopped during medication,
so our aim, first of all, lies in that direction, then on medication
and in complete remission of consuming drugs, which means that
your craving is completely under control and your rehabilitation
is successful. Yes, detoxification or medication is an issue,
too often leading to relapse. In my field, in my experience, I
am talking about patients where the disease has become very irreversible,
and I think the constant pressure on them not only from their
environment but also from within, from themselves, to combat abstinence
against their biological disturbances that is not professional.

848. You are saying they are safer on prescribed
heroin than they are on coming off the drug and relapse, is that
what you are saying?
(Dr van Santen) If you withdraw from medication too
early or too quickly then withdrawal itself is the cause of the
relapse, that is what I am saying.

849. Do you have any figures on the numbers
you treated who have come off heroin?
(Dr van Santen) In a methadone outpatient clinic substitution
treatment shows five per cent of people becoming abstinent from
medication. If you look at the design of heroin experimentees
amongst participants in some cases we have some case become abstinence
while on heroin treatment. We are lucky that the natural history
of this disease that when the patients get older their craving
for drugs and loss of control improve, we are helped by the nature
of this disease.

Mr Malins

850. Could I ask you both about something called
naltrexone, the heroin blocking drug, could I ask if you used
it? Am I right in saying that if I was heroin addict and I took
naltrexone it would simply block out the need for it? What do
you both say?
(Dr van Santen) Naltrexone is a classic antagonist
of heroin and methadone. The studies which have been done internationally,
mainly in the United States, and also currently in Holland, where
people are detoxified very rapidly and put on naltrexone can be
positive. In my experience you need an array of services and you
need different situations of treatment, this is one of them. Technically
it is very simple to integrate this treatment in your treatment
programme. In our clinics we cannot sell it so very good.

851. You cannot? Do you use it?
(Dr van Santen) We cannot sell it. People do not accept
it. They need to go through withdrawal and the research which
is being done now in Holland, there is a programme where people
are hospitalised for a few days for rapid detoxification and put
on naltrexone afterwards. This is being published mid 2002.

852. Right. Dealing with your treatment options
for addiction, is diamorphine offered as one choice out of a menu
of treatment options?
(Dr van Santen) I think so, yes.

853. It is. Are they given their choice on request?
(Dr van Santen) You need professionalism in between.
I think that a professional team, which is a multi disciplinary
team, can in its assessment make indications for the different
treatments modalities, yes.
(Professor Rehm) Can I just go back to naltrexone,
I think naltrexone was the one medication which has been scientifically
supported the most in terms of money and resources although the
are overall results of naltrexone trials are not that strong.

854. All right.
(Professor Rehm) Especially over the long term. If
you look it is used now in almost all countries as part of the
rapid detoxification part. It is sometimes used as support and
sometimes used for very specific case.

855. Let me ask you this question arising out
of that, is there any research going on anywhere and is there
ever going to be a possibility that we will discover a drug which
will, so to speak, overnight, stop the need for heroin? What does
the future hold on wonderful cures, any prospect?
(Professor Rehm) There is research going on very clearly
there are some hopes with regard to genetic research.

856. Genetics.
(Professor Rehm) Genetically produced drugs. There
is more research going on worldwide, financed mainly by the National
Institute of Health in the US and thereby NIDA, the National Institute
of Drug Abuse on cocaine than on heroin. The problem overall is
that whenever you do genetic research on drugs you come to the
conclusion that it is not one gene which is responsible for it
but it is a multitude of different interactions. That means that
while nobody will exclude that such a medication sometimes may
be possible it is not round the corner and we will have decades
in order to solve the problem otherwise.

857. Decades? Many years?
(Professor Rehm) Yes. Lots of societies have problems
now and while genetic research is fully supported for long range
goals we need to have short-term fixes.

858. I understand. Finally, the programmes to
which you have been referring, do they require patients to take
their diamorphine in a particular way, injecting orally or are
there any other problems with this?
(Dr van Santen) One of the differences between Holland
and Switzerland is the percentage of people who do not inject
is much higher, the majority inhale heroin. In the design they
also offer heroin for inhalation and most of the participants
of the experiment with the experiment are only inhaling. Diamorphine
is being offered in an injectable form and in a form for inhaling.
Can I add something on the issue of pharmacotherapy and addiction
where you ask for future discoveries. I am not saying that I am
quite satisfied with the existing possibilities but I want to
make a little comparison between the pharmacotherapy for depression
compared to opiate addiction. With existing medications the results
for opiate addiction are better than for depression, so it is
all very relative, I think. Why should we wait for a magical cure
for addiction, where there is effective treatment, pharmacotherapy
and not use it, whereas for depression, for instance, there is
no such reluctance.

859. Thank you both very much.
(Professor Rehm) What we are doing right now, our
agency which is controlling medication clearly stated that evaporated
heroin used in Holland would not get their approval, no medication
would get their approval. For those people not injecting we are
using different forms of tablets.